Endoscopic submucosal dissection (ESD) is a new endoscopic treatment for early gastric cancer that enables complete resection of lesions in the lump. ESD has become widespread as a standard treatment because several devices, including high-frequency electro surgical units, injection solutions and endoscope with water jet, have been developed in Japan. Large lesions and lesions with an ulcer scar can be removed en bloc, and ESD has increased accordingly with the expanded indications. In addition, an accurate histopathological diagnosis can be made following en bloc resection. In this procedure, the circumferential mucosal incision around the lesion and the submucosa is dissected using an IT knife, hooking knife, electro-surgical snare (a thin type), flex knife or flush knife. In particular, the flush knife can emit a jet of water from the tip of a sheath that allows us to perform ESD efficiently. It is relatively safe for avoiding perforation and bleeding. However, ESD takes longer and requires advanced technical skill, and the incidence of major complications is higher in comparison with the standard EMR method. Therefore, it is desirable to learn all of the techniques and the characteristics of the devices and high-frequency units, as well as cutting, dissection and hemostasis in order to perform ESD safely.

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乳腺内視鏡手術は内視鏡手術手技により手術創の縮小化と移動を実現し整容性と手術効果の両面を満足させることができる乳房温存手術であり，日本で独自に開発された術式である．各術式は腋窩アプローチ法，傍乳輪アプローチ，外側アプローチ法，乳房下アプローチ法に分類され，それぞれ完全内視鏡手術と内視鏡補助手術が行われている．腫瘍径 2 cm 以上では何らかの乳房の変形が生じるため再建術の併用が必要と思われた．当科では現在セルロース，コラーゲンによる充填法を施行しており良好な成績を得ている．乳腺内視鏡手術は無作為比較試験による直接的証明はされていないものの従来法と同等の手術効果と安全性を持ちかつ整容性の面では優れている事から今後の普及が期待される術式である．しかしその最大の目的である整容性を保持するためには厳格に適応を守り，内視鏡手術特有の合併症について十分な対策を立てておく必要がある．

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従来，下肢慢性静脈不全に伴う下腿のうっ滞性皮膚炎，色素沈着および潰瘍といったうっ滞症候群に 対しての術式は，lipodermatosclerosis により硬化した病的皮膚を直接切開し，不全穿通枝を筋膜下で処理するLinton 手術などが行われてきた．しかし，病的皮膚を直接切開することで術後創合併症が必発とされていた．そこで，我々は 1999 年より内視鏡を用いた不全穿通枝切離術 (subfacial endoscopic perforator surgery, SEPS) を施行し，術後創合併症を軽減するとともに本来の目的である皮膚病変の改善が得られる症例を多く経験するようになった．SEPS の詳細を実際の症例を交えて報告する．

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Laparoscopic surgery has been widely performed for various diseases around the world, ever since the first successful laparoscopic cholecystectomy in 1987. Initially, laparoscopic surgery was only indicated for benign disease; however, its application has now been expanded to malignancies, such as colon, esophageal and gastric cancer. In particular, laparoscopic surgery for gastric cancer is flourishing in Japan. Laparoscopic partial gastrectomy for gastric cancer was first reported in 1993 and laparoscopy-assisted distal gastrectomy with lymph node dissection was reported in 1994. However, this approach took some years to become popular even among the laparoscopic surgeons. We began using laparoscopy-assisted distal gastrectomy for gastric cancer in 1996 and have performed more than 200 cases by now. In this manuscript, we report our standardized procedure and the outcomes of laparoscopic gastrectomy with hand-assisted laparoscopic surgery (HALS).

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This paper presents an overview of neuroendoscopic surgery. Innovations in optical engineering have raised the quality of the instrumentation for neuroendoscopy and have provided us with opportunities to perform therapeutic procedures through small, minimally invasive exposure with little disruption of neuronal structures in neurological surgery. As a result, various neuroendoscopic procedures, such as endoscopic third ventriculostomy (ETV), endoscopic transnasal-transsphenoidal surgery, etc., have been developed. For a patient to be considered a candidate for endoscopic third ventriculostomy (ETV), two criteria must be met. First, there must be a symptomatic noncommunicating hydrocephalus. Second, the subarachnoid space must be open and able to absorb cerebrospinal fluid (CSF). In the setting of noncommunicating hydrocephalus, there is absorption of CSF between the ventricles and the subarachnoid space to the circulation. In third ventriculostomy, a fenestration is established in the floor of the anterior third ventricle, allowing CSF to be shunted into the basal cistern, where it can then be absorbed into the venous system. Endoscopic transnasal-transsphenoidal surgery for pituitary tumor, especially pituitary adenoma, has permitted a direct transnasal approach to the sphenoidal sinus, without dissection of the septal mucosa, thus, reducing postoperative morbidity.

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Endoscopic surgery is useful in Otorhinolaryngology and particularly epoch-making apparatus for improving sinus surgery has been developed since the 1980s. Recently, endoscopic surgery has been used for minimally invasive middle ear surgery, laryngeal surgery and skull base surgery. NBI (Narrow Band Imaging) has been used for operating in the early stages of pharyngeal malignancy. Neuroendoscopic Surgery.

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We have routinely performed transurethral surgery, which shows unique urological peculiarity, for over a hundred years. The recent developments and technological advances in urological laparoscopic surgeries are also remarkable. Nowadays, endourology consists of 4 surgical approaches; including the transurethral, laparoscopic, retroperitoneal and percutaneus approach. Herein, we describe the recent advances of endoscopic surgeries in Urology.

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Epiphora, or watering eye, is commonly caused by lacrimal duct stenosis or obstruction. Lacrimal endoscopy is useful not only for observation of the inner lumen of the lacrimal duct but also for direct endoscopic probing of obstructive lacrimal lesions. In this procedure, a fine endoscopic probe can be introduced from the upper or lower punctum of the lids to the orifice of nasolacrimal duct (NLD) into the inferior meatus. The endoscopy procedure usually requires local anesthesia, through infratrochlear nerve block and nasal instillation. The occurrence and distribution of the obstruction sites of NLD were studied using endoscopy. The most frequent obstruction site was the lower portion of NLD. By using endoscopy and silicone tube intubation for NLD obstruction, the success rate of the treatment was improved much greater than without endoscopy. The future and limitations of lacrimal endoscopy are discussed.

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There are many women with fibroids or endometriosis. Since endoscopic surgery was approved for insurance coverage in Japan, these procedures have increased dramatically. Recently the incidence of laparoscopic surgery for benign disease has reached over 95 percent in our hospital, Nihon University Surugadai Hospital, and our institution is designated as a high performance level hospital in Japan. As there is the important problem of cost-benefit, e.g. because of the high cost of disposable instruments, we use reusable forceps in our hospital. It is clinically important to carefully evaluate benign tumors. After the preoperative status of uterine fibroids and ovarian tumors has been evaluated regarding tumor size, location and possibility of malignancy, we determine whether laparoscopic surgery or laparotomy is the best operation for the patient. The ultimate aim of infertility management is for women to go to term safely upon becoming pregnant. Although malignant tumors are contraindications for laparoscopic surgery at present, we believe that in the future malignant tumors are going to be treated laparoscopically following careful evaluation of each case. Difficult operations are more easily performed than previously, due to the increase of skills. Meanwhile, there have been various reports on several unexpected accidental complications. We must improve the management of emergencies and the prevention of accidental complications.

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The Japan Orthopedic Association has led the way with endoscopic surgery for the spine and has developed its own training course and technical authorization system. Endoscopic surgery can be classified roughly as an anterior procedure from the pleural or peritoneal cavity or as a posterior procedure from the posterior interlaminar space in spine endoscopic surgeries. A representative technique of the endoscopic posterior spine surgery, which uses the posterior method, is microendoscopic discectomy (MED). While MED was initially utilized for lumbar herniotomy, it has recently been used for lumbar spinal canal stenosis and cervical spine disease. Therefore, all the posterior operative procedures are generally used with an MED system and they are referred to as MED. Thus, MED accounts for 98.7% of spine endoscopic operations performed in Japan (2006). There is little soft tissue damage with this approach and the lamina can be reached between the muscles for lumbar disc herniation. In the MED, radiographic control is indispensable for localization of the tube retractor, and it is necessary to resect the yellow ligament little by little to divide the superficial layer and the deep layer. MED is superior in visual safety for retraction of the nerve root to herniotomy. As for issues with MED, there is a substantial learning curve, the operation requires a long time, expensive instrumentation, there is the lack of haploscopic vision, the visual field to operate is limited, there is a tendency to become disoriented, and the lack of sensation of palpating an organ. Additional approaches include video-assisted thoracoscopic spine surgery (VATS) and endoscopic anterior lumbar spine surgery via the peritoneal or retroperitoneal cavity, but they do not lead to global operations.

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頭頂連合野は感覚情報を統合するのに重要な役割を果たしていると考えられてきたが，近年，運動制御にも関与していることが明らかになってきた．しかし，頭頂連合野と一次運動野の間には直接の神経連絡はない．したがって，頭頂連合野からの情報は運動関連領野を介して間接的に一次運動野に送られると考えられるが，それを実証した研究は未だない．

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急性間質性肺炎は急速に進行する重症の肺障害であり，胸部画像所見では両側性のびまん性または斑状の浸潤影を呈する．症例 1 は発症時より両側肺野にすりガラス状影を示し，症例 2 は両側肺野末梢の斑状の濃い浸潤影から病変が進行した．2 例とも進行性の呼吸不全で死亡し，剖検を行ったところ肺の病理組織像はびまん性肺胞障害であり，特に症例 2 は肺胞腔内への強い滲出と腔内器質化病変が混在し， 進行性の病態が確認された．

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症例は 58 歳，男性．55 歳より近医で糖尿病を指摘され，56 歳より当科で α -グルコシダーゼ阻害薬の内服を行っていたが，血糖コントロール不良であった．大腸内視鏡検査において切除適応のポリープとともに S状結腸に散在性の小びらんを認めていた．2 年後の大腸ポリペクトミー時に直腸から S 状結腸まで多発する粘膜下腫瘍様の隆起性病変を認めた．注腸検査でも同様の所見であった．以上より腸管嚢腫様気腫症と診断し，α -グルコシダーゼ阻害薬を原因と考え，投薬を中止し外来経過観察とした．α -グルコシダーゼ阻害薬の関与が疑われた腸管嚢腫様気腫症の 1 例を経験したので報告する．

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症例は 86 歳の女性．大腸癌術後で外来通院中，腹部 CT 検査にて，胃十二指腸動脈領域に約 28 mm 大の腹側に突出する紡錘状の腫瘤像を認め，腹部血管造影にて胃十二指腸動脈瘤と診断した．本症例は瘤径が比較的大きく，破裂の危険性もあったため，経動脈塞栓術にてコイル塞栓術を行った．その結果，動脈瘤は完全に塞栓され，施行後 1 ヶ月も経過良好で現在も引き続き外来follow up 中である．

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一般に微小変化型ネフローゼ症候群はステロイド療法に良好に反応して予後は良好であるが，低蛋白血症による循環血漿量の低下，ひいては腎血流量の低下を原因の一つとして可逆性の急性腎不全を来す事がある．一年前に腎生検で微小変化群と診断されステロイドの内服のもと外来経過観察中であったが，感染や過度の運動を機に再発．急性腎不全を呈してステロイドパルス療法の後，血液浄化療法も併用して寛解に至った症例を経験したので報告する．

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